The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
| ABILENE BEHAVIORAL HEALTH LLC | 4225 WOODS PLACE ABILENE, TX | Oct. 24, 2012 |
| VIOLATION: CONTRACTED SERVICES | Tag No: A0083 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on direct observation, record review, and interviews, it was determined that the governing body failed in its responsibility to ensure that services provided were in compliance with all applicable conditions of participation and standards. Findings were: Facility Based Policy entitled " Documentation Procedure/Error Correction/Authorized Personnel " stated in part, " Time Documentation ... ? All medical record entries must be signed, dated, and timed by the author. Telephone/Verbal orders must follow read-back procedures and be signed within forty-eight (48) hours or twenty-four hours for admit orders. " Facility Based Policy entitled " Medical Order-Verbal " stated in part, " e. Verbal orders will be subsequently authenticated (verified) and countersigned by the prescribing practitioner or other responsible practitioner within 72 hours. " A review of Patient #1 and #2's medical records review verbal orders that were not countersigned by the physician within 48-72 hours. Patient #1 had 4 telephone orders countersigned by the physician without a date or time noted. 1 verbal order was documented on 08/18/12 and countersigned on 10/02/12. Patient #2 had 3 verbal orders on 09/18/12 and countersigned on 10/02/12. Facility Based Policy entitled " Patient Consent for Psychoactive Medications-Typical, Emergency, & Court-Ordered " stated in part, 5. When the legally authorized representative is not present, telephone or faxed consent may be obtained providing: a. Two staff members, one of whom must be a licensed nurse, document the telephone conversation with the legally authorized representative which includes all aspects of the informed consent mentioned above, on the Consent to Psychoactive Medication Form. b. The consent form can be faxed to the legally authorized representative, and the returned signed form placed on the chart. c. At such time as the legally authorized representative is in the hospital, they will be asked to sign the original copy ... 7. No psychoactive medication will be administered at Acadia Abilene without completion of the informed consent process with the exception of administration of psychoactive medication in the event of an emergency situation (see definition of emergency). " A review of Patient #"2 medical record revealed a Verbal Psychoactive Consent for Medication with only one witness signature present. According to the medication administration record, Patient # 2 received Focalin XR Capsule, Extended Release 20 mg 1 PO daily q AM at 0800 from 09/21/12 through 09/28/12. Facility Based Policy entitled " Seclusion and Restraint " stated in part, "B. Personal Restraint...13. Modify patient ' s Treatment Plan based upon information gathered during debriefing ... " A review of Patient #2's medical record revealed that he had 2 personal restraints while inpatient. A review of Patient #2's treatment team plans and updates revealed no update or medication related to the two personal restraints that occurred. Facility Based Policy entitled " Patient Grievance Procedure " stated in part, " 2. The patient wishing to file a grievance with the hospital will be encouraged to speak with the patient advocate or complete a patient advocate request form and submit it to the patient advocate ... 3. The patient advocate will respond to the request within 24 hours during the week and 72 hours on weekends. The patient advocate will present the complaint, a summary of the examination and, recommendations for follow-up to the appropriate supervisor/s attending physician. Appropriate action will be initiated in response to the patient advocate ' s report ... 7. Within 24 hours of interviewing the patient, the patient advocate will inform the patient of the response(s) taken. If the patient is unsatisfied with the action, the patient will be informed by the patient advocate that he/she may request that the unresolved issue be taken to the Hospital Administrator for resolution. A review of facility based documentation revealed that Patient #1 filled out 14 communication forms during his inpatient stay at the facility. Only 1 form dated 08/23/13 included follow up of " Passed onto CM and DON " There was no documentation that the Patient # 1's complaints were addressed and followed up per facility policy. There was no documentation that the patient advocate responded within 24-72 hours or presented the complaint, a summary of the examination and, recommendations for follow-up to the appropriate supervisor/s attending physician. There was no documentation that within 24 hours of interviewing the patient, the patient advocate will informed the patient of the response(s) taken. Facility Based Document entitled " Admission Booklet Patient ' s Bill of Rights " stated in part, " Basic Rights For All Patients ...Voluntary Patients-Special Rights 1. You have the right to request discharge from the hospital. If you want to leave, you need to say so in writing or tell a staff person. If you tell a staff person, the staff person must write it down for you. 2. You have the right to be discharged from the hospital within four hours of requesting discharge. There are only three reasons why you would not be allowed to go: ? First, if you change your mind and want to stay at the hospital, you can sign a paper that says you do not wish to leave, or you can tell a staff member that you don ' t want to leave and that staff member has to write it down for you ... ? Thirdly, you may be detained longer than four if your doctor has reason to believe that you might meet the criteria for court-ordered services or emergency detention because: o You are likely to cause serious harm to yourself; o You are likely to cause serious harm to other; or o Your condition will continue to deteriorate an you are unable to make an informed decision as to whether or not to stay for treatment. If your doctor thinks you may meet the criteria for court ordered services or emergency detention, he or she must examine you in person within 24 hours of your filing the discharge request. " Facility Based Policy entitled " Patient Rights-Description & Procedure " stated in part, "ADDITIONAL RIGHTS OF VOLUNTARY PATIENTS 1. The right to request discharge (see Request for Release Policy). " Facility Based Policy entitled " Request for Release " stated in part, " Voluntary patients over the age of 16 have the right to request their release from the facility at any point during the course of treatment ... PROCEDURE: Adult Patient or Parent/Legal Guardian Request 1. If an adult patient requests to be released or the parent/legal guardian requests the release of a voluntarily admitted adolescent patient, the Charge RN asks the requestor to complete the form titled, Request for Release. The form is witnesses by the staff persona and placed in the medical record. If the requestor is unable to complete the form, the staff member completes the form. The Charge RN explains to the patient that the physician has four hours to make a decision. 2. The Charge RN or her/his designee, talks with the patient or parent legal guardian to explore the reasons for the request and encourages the requestor to remain until the planned discharge date . 3. If the patient or parent/legal guardian continues to request the release, the Charge RN notifies the Case Manager and other significant team members. A treatment team meeting is called to allow all parties to discuss the issues and attempt to plan a mutually agreed upon discharge date ... 5. If the requestor continues to insist on leaving, the attending physician (or on-call physician if the request is made after hours/weekends/holidays) is contacted. The physician has four hours from the initial request for discharge to make one of the following decisions: a. If the physician believes the patient should not be discharged , he/she will order pursuit of an " Order of Protective Custody " (See Policy " Court Ordered Mental Health Services " ). Staff will notify patient of decision to pursue court ordered mental health services. b. If the physician does not believe that that patient meets criteria for court ordered mental health services, he/she gives an order to: i. Discharge the patient outright; or ii. Discharge the patient against medical advice (AMA). " Per documentation, Patient # 1 made statements indicating a desire to leave the facility and/or be discharged . Patient # 1 was on voluntary status while inpatient. Nursing Notes documented the following: ? Daily Nursing assessment dated [DATE] at 1200 stated, " B: Anxious, upset and said he has been lied to-wants to leave and wants AMA and pt communication form at 0900. I: Allowed pt to express his feelings and concerns and will give pt a communication form. " ? Evening Nursing assessment dated [DATE] at 1800 stated, " R: Pt demanded to go home AMA but MD and CM explained protocol and pt decided to stay and follow the rules. " Physician Daily Progress Note: On 08/24/12 at 03:45 PM stated, " Got a good night ' s rest so allowed to start day off right. Yesterday wanted to go AMA-given Haldol 5/Ativan2/Benadryl 25 IM X1. Happy to be here." There was no documentation in the medical record of Patient #1 that this patient was assisted in requesting discharge, which is a right of patients on voluntary status. There was no written request for discharge in the patient ' s medical records. There was no Request for Release for Release in the patient ' s medical record. There is no documentation in the medical record that once the patient stated that he wanted to leave, that he was instructed to request the discharge in writing nor assisted by staff to make this request in writing. There is no documentation that the physician was notified of the patients' request for discharge on 08/19/12. The medical record contained no documentation that the patient changed his mind about wanting to leave the hospital and/or signed a paper stating he did not wish to leave. The patient was not discharged within 4 hours of requesting discharge, nor is there documentation that the physician determined he met the criteria for court-ordered mental health services or filed an application for court-ordered mental health services. |
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| VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS | Tag No: A0116 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policies, documentation, and interview, it was determined that the facility failed to ensure that the notice of rights requirement were met. Findings Included: Facility Based Document entitled " Admission Booklet Patient ' s Bill of Rights " stated in part, " Basic Rights For All Patients ...Voluntary Patients-Special Rights 1. You have the right to request discharge from the hospital. If you want to leave, you need to say so in writing or tell a staff person. If you tell a staff person, the staff person must write it down for you. 2. You have the right to be discharged from the hospital within four hours of requesting discharge. There are only three reasons why you would not be allowed to go: ? First, if you change your mind and want to stay at the hospital, you can sign a paper that says you do not wish to leave, or you can tell a staff member that you don ' t want to leave and that staff member has to write it down for you ... ? Thirdly, you may be detained longer than four if your doctor has reason to believe that you might meet the criteria for court-ordered services or emergency detention because: o You are likely to cause serious harm to yourself; o You are likely to cause serious harm to other; or o Your condition will continue to deteriorate an you are unable to make an informed decision as to whether or not to stay for treatment. If your doctor thinks you may meet the criteria for court ordered services or emergency detention, he or she must examine you in person within 24 hours of your filing the discharge request. " Facility Based Policy entitled " Patient Rights-Description & Procedure " stated in part, "ADDITIONAL RIGHTS OF VOLUNTARY PATIENTS 1. The right to request discharge (see Request for Release Policy). " Facility Based Policy entitled " Request for Release " stated in part, " Voluntary patients over the age of 16 have the right to request their release from the facility at any point during the course of treatment ... PROCEDURE: Adult Patient or Parent/Legal Guardian Request 1. If an adult patient requests to be released or the parent/legal guardian requests the release of a voluntarily admitted adolescent patient, the Charge RN asks the requestor to complete the form titled, Request for Release. The form is witnesses by the staff persona and placed in the medical record. If the requestor is unable to complete the form, the staff member completes the form. The Charge RN explains to the patient that the physician has four hours to make a decision. 2. The Charge RN or her/his designee, talks with the patient or parent legal guardian to explore the reasons for the request and encourages the requestor to remain until the planned discharge date . 3. If the patient or parent/legal guardian continues to request the release, the Charge RN notifies the Case Manager and other significant team members. A treatment team meeting is called to allow all parties to discuss the issues and attempt to plan a mutually agreed upon discharge date ... 5. If the requestor continues to insist on leaving, the attending physician (or on-call physician if the request is made after hours/weekends/holidays) is contacted. The physician has four hours from the initial request for discharge to make one of the following decisions: a. If the physician believes the patient should not be discharged , he/she will order pursuit of an " Order of Protective Custody " (See Policy " Court Ordered Mental Health Services " ). Staff will notify patient of decision to pursue court ordered mental health services. b. If the physician does not believe that that patient meets criteria for court ordered mental health services, he/she gives an order to: i. Discharge the patient outright; or ii. Discharge the patient against medical advice (AMA). " Per documentation, Patient # 1 made statements indicating a desire to leave the facility and/or be discharged . Patient # 1 was on voluntary status while inpatient. Nursing Notes documented the following: ? Daily Nursing assessment dated [DATE] at 1200 stated, " B: Anxious, upset and said he has been lied to-wants to leave and wants AMA and pt communication form at 0900. I: Allowed pt to express his feelings and concerns and will give pt a communication form. " ? Evening Nursing assessment dated [DATE] at 1800 stated, " R: Pt demanded to go home AMA but MD and CM explained protocol and pt decided to stay and follow the rules. " Physician Daily Progress Note: On 08/24/12 at 03:45 PM stated, " Got a good night ' s rest so allowed to start day off right. Yesterday wanted to go AMA-given Haldol 5/Ativan2/Benadryl 25 IM X1. Happy to be here." There was no documentation in the medical record of Patient #1 that this patient was assisted in requesting discharge, which is a right of patients on voluntary status. There was no written request for discharge in the patient ' s medical records. There was no Request for Release for Release in the patient ' s medical record. There is no documentation in the medical record that once the patient stated that he wanted to leave, that he was instructed to request the discharge in writing nor assisted by staff to make this request in writing. There is no documentation that the physician was notified of the patients' request for discharge on 08/19/12. The medical record contained no documentation that the patient changed his mind about wanting to leave the hospital and/or signed a paper stating he did not wish to leave. The patient was not discharged within 4 hours of requesting discharge, nor is there documentation that the physician determined he met the criteria for court-ordered mental health services or filed an application for court-ordered mental health services. |
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| VIOLATION: PATIENT RIGHTS: GRIEVANCES | Tag No: A0118 | |
| Based on a review of facility policies, documentation, and interview, it was determined that the facility failed to ensure that established processed for patient grievance were followed and patient were informed of whom to contact to file a grievance. Findings Included: Facility Based Policy entitled " Patient Grievance Procedure " stated in part, " 2. The patient wishing to file a grievance with the hospital will be encouraged to speak with the patient advocate or complete a patient advocate request form and submit it to the patient advocate ... 3. The patient advocate will respond to the request within 24 hours during the week and 72 hours on weekends. The patient advocate will present the complaint, a summary of the examination and, recommendations for follow-up to the appropriate supervisor/s attending physician. Appropriate action will be initiated in response to the patient advocate ' s report ... 7. Within 24 hours of interviewing the patient, the patient advocate will inform the patient of the response(s) taken. If the patient is unsatisfied with the action, the patient will be informed by the patient advocate that he/she may request that the unresolved issue be taken to the Hospital Administrator for resolution. A review of facility based documentation revealed that Patient #1 filled out 14 communication forms during his inpatient stay at the facility. Only 1 form dated 08/23/13 included follow up of " Passed onto CM and DON " There was no documentation that the Patient # 1's complaints were addressed and followed up per facility policy. There was no documentation that the patient advocate responded within 24-72 hours or presented the complaint, a summary of the examination and, recommendations for follow-up to the appropriate supervisor/s attending physician. There was no documentation that within 24 hours of interviewing the patient, the patient advocate will informed the patient of the response(s) taken. |
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